CPAs & ADVISORS PHYSICIAN ALIGNMENT STRATEGIES. experience clarity // Moving Forward in the Health Reform Era

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1 CPAs & ADVISORS experience clarity // PHYSICIAN ALIGNMENT STRATEGIES Moving Forward in the Health Reform Era

2 OVERVIEW Physician alignment is a key in achieving Triple Aim -type outcomes Alignment opportunities are always driven by local facts & circumstances, requiring a broad tool kit to realize Discipline in implementation & execution drive overall outcomes Hospital-level affiliation & alignment require additional thoughtfulness & present new challenges & opportunities 2 // experience clarity

3 PART ONE ALIGNMENT TOOLS 3 // experience clarity

4 ALIGNMENT TOOL KIT SUMMARY Type of Arrangement Potential Alignment Value Financial Cost Complexity On-call Low High Low Medical Direction Low Low Low Co-management Arrangement High Medium Med-High Professional Services Agreement Medium Medium Med-High Employment High High Medium Clinical Joint Venture Low-Med High High Accountable Care Organization High Med High 4 // experience clarity

5 ON-CALL ARRANGEMENTS // Hospital engages a physician or physician group to provide guaranteed clinical coverage at its facility(ies) // Fee is typically per shift or per episode // Physician typically bill for professional services rendered & retain collections // Physicians are compensated for (in theory): Inconvenience Un- & Under-compensated Care Provided // Compliance Concerns Bona Fide Need Overlapping /Stacked Services Payment for Lost Opportunity Rates for Employed Physicians v. Independent Physicians 5 // experience clarity

6 MEDICAL DIRECTION // Hospital engages a physician to provide unique clinical insight necessary for hospital operations, accreditation, management, etc. // Compensation is typically based on hourly rates & paid annually or per documented hours worked. // Time is administrative in nature & no billings are associated with these activities // Physicians are compensated for their time & expertise in clinical matters // Compliance concerns Overlapping agreements with multiple providers Undocumented services Undelivered services Fees based on clinical opportunity cost 6 // experience clarity

7 CO-MANAGEMENT ARRANGEMENTS // Hospital engages physician or a physician-owned entity to provide management services on its behalf for some component of its inpatient or outpatient services // Hospital & physicians collaborate by having physicians co-manage a service line // Co-Management company contracts with hospital to manage service line // Agreement can be with one or more physicians, medical practices, or a joint venture company owned jointly by physicians & a hospital // Compensation typically includes a fixed base fee & a bonus for achievement of specific quality or other performance measures // Time is administrative in nature & no billings are associated with these activities // Physicians are compensated for providing management services, including medical direction, budgeting, scheduling, HR, materials management, protocol development for performance improvement, safety, quality, satisfaction, etc. // Compliance concerns include reduced services/access, weak goals, & fees disproportionate to services rendered 7 // experience clarity

8 PROFESSIONAL SERVICES ARRANGEMENTS Hospital engages a physician or physician group to provide clinical services & (sometimes) other services on its behalf while physician(s) remains an independent contractor. May also include costs other than labor Compensation to the physician is typically a fixed amount per unit of service Billing rights for professional services are assigned to, and billed by, the hospital Physicians are compensation for the provision of professional medical services on an independent contractor basis Compliance concerns Billing & coding Rate setting Employment v. independent contractor status Fees based on practice overhead 8 // experience clarity

9 EMPLOYMENT Hospital hires a licensed physician to provide professional medical services directly to the community. Hospital engages physician pursuant to an employment contract, typically including a covenant not to compete Compensation to the physician varies widely & including methodologies such as salary, production-based, revenue less expense, per shift, etc. Billing for professional services is integrated with the hospital Physicians are compensation for the provision of professional medical Compliance concerns Calculation of compensation terms Stacked/overlapping arrangements Compensation disproportionate productivity 9 // experience clarity

10 CLINICAL JOINT VENTURE Hospital & physicians enter into a business arrangement as equity partners Compensation to the physician is typically based on a combination of the distributions of the business entity & any capital gains achieved in the value of the business Billing for professional services is not applicable. The joint venture operating entity bills directly for services it renders Physicians are typically passive investors & are only compensated for their capital investment & associated risk in the operating business Compliance concerns Certificate of Need restrictions Compensation for labor versus return on investment Billing & collections rules 10 // experience clarity

11 ACCOUNTABLE CARE ORGANIZATION Hospital and/or physician (or other) group form an entity centered around a reimbursement & care delivery model that seeks to tie provider reimbursements to quality metrics & reductions in the total cost of care for an assigned population of patients Generally compensation is fee for service for the respective provider types participating in the arrangement. ACOs also feature a shared savings incentive for beating cost expectations Physician compensation is for the provision of professional medical services on an independent contractor basis Compliance concerns Reducing services to beneficiaries Patient & performance attribution 11 // experience clarity

12 PART TWO PHYSICIAN ORIENTED STRATEGY 12 // experience clarity

13 ALIGNMENT STRATEGIES BIG PICTURE Hospitals must assess where its strategic needs are & be proactive in seeking & developing alignment opportunities Prioritization is important in an effective allocation of resources Some strategic needs may best be met through hospital-tohospital affiliation networks Physician leadership is critical in all clinical integration efforts Compliance can be a concern both from a fair market value standpoint as well as from an anti-competitive standpoint 13 // experience clarity

14 ALIGNMENT STRATEGIES - PROCESS Standard due diligence should be formally documented Systematic approach should include input from key stakeholders in operations, finance, IT, compliance, legal, etc. Timing of due diligence should include key go / no-go milestones Clear communication protocols with physician partners should be establish & adhered to All alignment initiatives need a project champion 14 // experience clarity

15 HEALTH CARE REFORM INFRASTRUCTURE Physician Supply Information Technology Physician Integration & Alignment Independent Physicians Employed Physicians Independent Physicians Payer Relationships Care Coordination Cost Management 15 // experience clarity

16 MEASURING SUPPLY: UTILIZING DEMAND BASED QUANTITATIVE TOOLS Consider utilizing various physician to population ratios as compared to supply both for the immediate medical service area as well as a broader geographic catchment area Consider using population use rates & demand based information to project estimated numbers of visits Primary Care Specialty Care Urgent Care Consider evaluating projected ambulatory surgery procedures using national population use rates Consider evaluating physician volume based on estimated number of visits/procedures & the estimated number of visits/procedures per FTE Allows for the calculation of expected number of FTEs based on expected demand information 16 // experience clarity

17 STRATEGIC PHYSICIAN SUPPLY & DEMAND CONSIDERATIONS Incorporate geographical & physician age sensitivity analysis Perform physician patient origin analysis to evaluate outmigration patterns & impact on admissions & other referral Identify potential outlying areas for clinic development and/or relocation Incorporate Nurse Practitioner & other Non-Physician Providers to the Physician Supply Database Create an additional analysis that captures the hospital s biggest referrers as FTE s that are more equal than others from a strategic standpoint. Analyze utilization by employed physician v. nonemployed physician by service line. Consider physician employment agreement expiration dates & create a control with service line leaders to determine if the parties are likely to renew the contract. 17 // experience clarity

18 CARE COORDINATION Typical Electronic Health Record System Current: Primarily utilized as a substitute for paper records in early stages of implementation Future: Actively mined for best practice applications & the hub for population management Concept of EHR system as key financial management tool Creation of Value-Based (outcome/cost) reporting on individual providers & on specific diagnoses Creation of provider-led care protocol development teams Creation of provider-led care protocol control processes implemented through EHR system in real time Expansion of primary market area health care continuum included within system controls through affiliations or other mechanisms Utilize mid-level providers for new EHR transitions 18 // experience clarity

19 CARE COORDINATION Typical Population Management Strategy Current: Geographic protections create a cohesive market for population management Future: Health care reform will likely drive care coordination needs (i.e. Patient Centered Medical Home, Bundled Payment models, etc.) Concept of managing (not necessary performing) delivery of all health care to primary market population Proactive enhancement of cohesiveness of primary market area Employers Civic leaders Patients Proactive expansion of care continuum under management for primary market population, through affiliations or other methods Pre-acute (specialty physicians & services, ancillaries) Acute (tertiary services) Post-acute (chronic illness, SNF, home care, long-term nursing) Development of population management infrastructure 19 // experience clarity

20 UTILIZING A SERVICE LINE/DEPARTMENTAL ANALYSIS Summary of Analysis: This analysis utilizes charges generated for patients defined in various service lines to allocate both revenue & expenses based generally on Medicare cost report allocation methodologies. Purpose: By holistically focusing on all areas of operation from a physician standpoint, this analysis can provide clarity around what types of alignment arrangements might be appropriate financial investments. 20 // experience clarity

21 SAMPLE NET PROFITABILITY BY BROAD SERVICE TYPE 21 // experience clarity

22 SAMPLE NET PROFITABILITY BY SERVICE LINE 22 // experience clarity

23 SAMPLE PROFITABILITY BY DEPARTMENT 23 // experience clarity

24 THANK YOU FOR MORE INFORMATION // For a complete list of our offices & subsidiaries, visit bkd.com or contact: Randy Biernat, CPA/ABV Director // Mark Blessing, CPA Partner //

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